Wednesday, September 24, 2008

Pain appears to be more common in individuals with Parkinson's disease than in those without, suggesting that pain is associated with the condition, according to a new report.

"Patients with Parkinson's disease often complain of painful sensations that may involve body parts affected and unaffected by dystonia," or involuntary muscle contractions, the authors write as background information in the article. This pain may resemble cramping or arthritis, or have features of pain caused by nerve damage. "The high frequency of these pain disorders in the general population makes it hard to establish whether pain is more frequent among people with Parkinson's disease than among age-matched controls."

Giovanni Defazio, M.D., Ph.D., of the University of Bari, Italy, and colleagues compared 402 patients with Parkinson's disease to 317 healthy individuals who were the same age. Participants provided information about their current age, the age at which they developed Parkinson's disease, scores on disease rating scales and details regarding any pain that was present at the time of the study and lasted for at least three months.

Overall, pain was more common among Parkinson's disease patients than among controls (281 or 69.9 percent vs. 199 or 62.8 percent). This was mainly attributable to dystonic pain, as rates of pain not associated with dystonia were similar among individuals with Parkinson's disease (267 or 66.4 percent) and those without (199 or 62.8 percent).

"Nevertheless, we observed a significant association between Parkinson's disease and non-dystonic pain, beginning after the onset of parkinsonian symptoms," the authors write. "Cramping and central neuropathic [nervous system–related] pain were more frequent among Parkinson's disease patients than controls. About one-quarter of patients who experienced pain reported pain onset before starting antiparkinsonian therapy."

Basal ganglia, structures deep in the brain that control movement and are damaged in patients with Parkinson's disease, also are involved with pain processing, the authors note. This might account for the increase in pain associated with Parkinson's disease.

"These data support the hypothesis that pain begins at clinical onset of Parkinson's disease or thereafter as a non-motor feature of Parkinson's disease," they conclude. "The findings of this study may have implications for designing studies aimed at understanding pain mechanisms in Parkinson's disease and identifying specific treatment strategies."

I had been hired by one of the nation's great newspapers. I was setting up a cute apartment in Dupont Circle. And yet my body was sending me a signal that all was not well: I was waking every morning with a throbbing pain in my jaw.

A dentist took one look into my sore mouth and pronounced me a victim of an affliction common among Type A people who move to Washington for stressful jobs.

Bruxism. I was grinding my teeth at night.

It was so bad that a diagnostic test, which involved sliding my teeth from side to side on a thin sheet resembling carbon paper, turned up several molars that were practically flattened and one that was starting to crack. At 35, I was losing my teeth.

It turns out that we are a nation of bruxers . About 10 percent of adults grind regularly, although dentists say that half of the population, including children, gnash at some point in their lives. But as many as half of the serious grinders don't seek treatment, either because they don't see a dentist or because the habit doesn't cause them pain. Eventually they'll wear right through their teeth, though, and that will be really painful -- as well as costly.

The long-term damage to teeth, gums and jaws can be severe, and don't forget fatigue from disturbed sleep. Grinding is side-to-side destruction, while less common clenching involves a bearing down that can bring on painful headaches.

Cave men probably wore out their teeth, too, dentists say, what with gnawing on bones and eating hard-to-chew foods that threw off their bite. Today's malady is triggered by the stress of such events as divorce or a new job, or by a bite that is misaligned just enough to prevent the teeth from meeting evenly when they close, triggering the instinct to gnash. That can cause jaw pain, called temporomandibular disorder, or TMD, because sliding your teeth around can stress the jaw joint and the muscles around it; conversely, the discomfort of TMD can cause more grinding. Consuming caffeine and alcohol can also aggravate the tendency.

Your teeth may seem destined to come together. But the average set of upper and lower teeth have less contact while chewing three meals a day than you might think, touching for a total of about eight minutes. In contrast, an aggressive grinder can go at it for as long as 80 minutes in a single night.

Many grinders have no idea they do it until a dentist tells them, they wake themselves up or their partners are awakened by loud crunching noises. And the underlying causes and remedies of bruxism still are poorly understood, partly because people don't grind consistently, making it more difficult to diagnose.

"The problem is that it's extremely variable," said Michael Smith, an associate professor of psychiatry at the Johns Hopkins School of Medicine who is leading a study of sleep disorders and jaw pain, including bruxism. "It waxes and wanes. We don't know what cause comes first."

Bruxism is only now getting attention from the academic world, as the field of sleep medicine takes off. A relatively small number of dentists go into research, hampering efforts to understand the disorder's causes and treatment.

Was there hope for me?

After my diagnosis, my dentist immediately made a mold of my teeth to measure me for a night guard, a plastic device that fits over the top or bottom teeth. The guard acts as a buffer, blocking the upper and lower enamels from contact. It does not stop the grinding. My custom-made guard cost $400, of which about $260 was covered by insurance. Not every policy is that generous.

(And not every tooth-grinder benefits from a guard. Really vigorous gnashers eventually wear right through them, and dentists say some of those bruxers need to deal with their stress by learning relaxation techniques and in therapy. "We're not asking about their mother and father or anything," said Edward Grace, a dentist and psychologist at the University of Maryland Dental School. "We recommend reducing stress in any way they thought possible.")

In my case, after a few adjustments my clear night guard was going to bed with me every night. It clicked snugly into place over my upper teeth, and when I closed my jaw my tongue felt only a smooth plastic surface. It looked like a pair of dentures, and its daytime home was a blue plastic case on the night table. My guard became a more valued traveling partner than my toothbrush: I would choose plaque over pain any day.

My jaw pain stabilized. I felt cured. I was still stressed out, of course, just not in pain.

My husband says my guard makes my morning breath stink. Small price to pay, I tell him as I run to the bathroom to rinse my mouth.

I've paid a different kind of price, though, in the seven years since my condition was diagnosed. Within four months I lost my guard, probably swept into the pile of dust under the bed by the cat or vacuumed up by the cleaning crew. I was fitted for another one but discovered that I would have to pay for it on my own, since my insurance policy covered just one "occlusal device" every three years. (Insurance companies must know how fast people lose these things.) A year later, that guard had been lost, too.

Guard No. 3 was a state-of-the-art model called an NTI-tss, which looked a lot simpler than its virtually unpronounceable technical name: nociceptive trigeminal inhibitory device. Shaped sort of like a mouth puckered up for a kiss, it sat snugly on my two front teeth. I loved its compact fit. But I left that one in a Holiday Inn in Norfolk, where I went to cover a speech by President Bush. I made a desperate call to the hotel, but it was gone. Probably it did not end up in the lost and found.

After No. 3 was gone, I opted for the $49, over-the-counter version to save money. I dutifully boiled my new guard in a pot on the stove to soften it before molding it to my teeth. Then I cut it to size with a scissors.

I put it in my mouth, quickly gagged and tossed it in the garbage can.

When I started commuting to our bureau in Annapolis two years ago, my new dentist fitted me with guard No. 5, this one to cover just my bottom teeth.

"Don't worry," he told me. "I think you'll be able to keep track of this one. We're going to make it brown, so you'll see it."

Sunday, September 21, 2008

The U. S. health-care system, according to "Uninsured in America," has created a group of people who increasingly look different from others and suffer in ways that others do not. The leading cause of personal bankruptcy in the United States is unpaid medical bills.

Half of the uninsured owe money to hospitals, and a third are being pursued by collection agencies. Children without health insurance are less likely to receive medical attention for serious injuries, for recurrent ear infections, or for asthma. Lung-cancer patients without insurance are less likely to receive surgery, chemotherapy, or radiation treatment. Heart-attack victims without health insurance are less likely to receive angioplasty. People with pneumonia who don't have health insurance are less likely to receive X rays or consultations. The death rate in any given year for someone without health insurance is twenty-five per cent higher than for someone with insurance.

Because the uninsured are sicker than the rest of us, they can't get better jobs, and because they can't get better jobs they can't afford health insurance, and because they can't afford health insurance they get even sicker. John, the manager of a bar in Idaho, tells Sered and Fernandopulle that as a result of various workplace injuries over the years he takes eight ibuprofen, waits two hours, then takes eight more—and tries to cadge as much prescription pain medication as he can from friends. "There are times when I should've gone to the doctor, but I couldn't afford to go because I don't have insurance," he says. "Like when my back messed up, I should've gone. If I had insurance, I would've went, because I know I could get treatment, but when you can't afford it you don't go. Because the harder the hole you get into in terms of bills, then you'll never get out. So you just say, 'I can deal with the pain.' "

Saturday, September 20, 2008

Brain researchers have begun to explore what might be called faith-based analgesia.

Stimulating a religious state of mind in devout Catholics triggers brain processes associated with substantial relief from physical pain, report neuroscientist Katja Wiech of the University of Oxford, England, and her colleagues in an upcoming issue of Pain.

"Our data suggest that religious belief alters the brain in a way that changes how a person responds to pain," says Oxford neuroscientist and study coauthor Irene Tracey.

Practicing Catholics perceived electrical pulses delivered to one hand while viewing an image of the Virgin Mary as less painful than pulses delivered while looking at a non-religious picture. Functional MRI showed a change in these volunteers' brain activity only while viewing the religious icon.

In contrast, professed atheists and agnostics derived no pain relief from viewing the same religious image while getting uncomfortably zapped on the hand.

"What's exciting is that this new study shows a neural mechanism by which religious belief affects pain perception," remarks psychiatrist Harold Koenig, codirector of the Center for Spirituality, Theology and Health at Duke University in Durham, N.C.

Wiech and her coworkers studied 12 professed Catholics and 12 professed atheists or agnostics, ranging in age from 19 to 34 years.

Religious volunteers attended Mass at least weekly, prayed everyday and regularly performed other religious activities, such as going to confession.

During testing, each participant lay in a functional MRI, a brain-imaging machine that measures the rise and fall in blood flow throughout the brain. Blood-flow changes in particular areas reflect increases and decreases in neural activity.

In alternating trials, volunteers first spent 30 seconds observing an image either of a painting of the Virgin Mary or Lady with an Ermine, a painting of a similar-looking woman by Leonardo da Vinci.

Images remained visible on a computer screen as participants then received 20 brief electrical pulses delivered to the back of the left hand. Pre-testing on each person had determined the pulse intensity needed to produce moderate pain.

Catholics reported feeling peaceful and secure, as well as thinking about compassion and other religious concepts, while viewing the Virgin Mary. They rated that image as especially helpful in coping with pain. Non-religious participants reported no advantage from either image in dealing with pain.

Pain relief for Catholics viewing the Virgin Mary was accompanied by vigorous activity in the right ventrolateral prefrontal cortex. Other researchers have linked this brain area to pain relief associated with emotional detachment and perceived control over pain. This brain response was not observed in the non-religious volunteers.

Any religious or non-religious belief system can provoke pain relief, Tracey proposes. Different religions may foster more or less pain in response to images of religious suffering, but peaceful images of worship probably evoke pain relief across religions, she says. A serene belief-related image causes a religious person to reinterpret the meaning of immediate pain, leading to a brain state that ratchets down pain intensity, Tracey posits.

Religious belief represents one of many ways to reappraise the meaning of pain, says psychologist Tor Wager of Columbia University. Emerging evidence suggests that successful placebo treatments activate the same brain region linked by Wiech's team to pain relief in religious volunteers, he notes. "Anyone can create new, positive meanings for aversive events, but they have to find thoughts or interpretations that they truly believe in," Wager holds.

Further work needs to determine whether religious volunteers derive brain-mediated pain relief because religious images simply engage or distract their attention or because the images spark religious thoughts and feelings, comments neuroscientist Matthew Lieberman of the University of California, Los Angeles.

"Car enthusiasts shown car pictures would report less pain under the first explanation, but not under the second," Lieberman says.

ANN ARBOR, Mich. —This week, University of Michigan scientists will begin a phase 1 clinical trial for the treatment of cancer-related pain, using a novel gene transfer vector injected into the skin to deliver a pain-relieving gene to the nervous system.

A gene transfer vector is an agent used to carry genes into cells. In this groundbreaking clinical trial, the investigators will use a vector created from herpes simplex virus (HSV) – the virus that causes cold sores – to deliver the gene for enkephalin, one of the body’s own natural pain relievers.

“In pre-clinical studies, we have found that HSV-mediated transfer of enkephalin can reduce chronic pain,” says David Fink, M.D., Robert Brear Professor and chair of the department of neurology at the U-M Medical School. Fink developed the vector with collaborators and will direct the study.

“After almost two decades of development and more than eight years of studies in animal models of pain, we have reached the point where we are ready to find out whether this approach will be effective in treating patients,” Fink says. The investigators are recruiting 12 patients with intractable pain from cancer to examine whether the vector can be used safely to deliver its cargo to sensory nerves.

The trial represents two firsts, says Fink: It is the first human trial of gene therapy for pain, and the first study to test a nonreplicating HSV-based vector to deliver a therapeutic gene to humans. Fink says the technique may hold promise for treating other types of chronic pain, including pain from nerve damage that occurs in many people with diabetes.

The HSV vector, genetically altered so it cannot reproduce, has a distinct advantage, Fink says: “Because HSV naturally travels to nerve cells from the skin, the HSV-based vector can be injected in the skin to target pain pathways in the nervous system.”

Gene therapy for pain

Chronic pain is an important clinical problem that, despite a wide array of therapeutic options, cannot be effectively treated in a substantial number of patients. Fink notes that one key problem in treating pain is that the targets of conventional pain-relieving medications tend to be widely distributed in the nervous system, so that “off target” side effects of the drugs often preclude the use of those drugs at fully effective doses.

“This provides the rationale for using gene transfer to treat pain,” Fink says. “We use the vector to deliver and express a chemical that breaks down very quickly in the body. The targeted delivery allows us to selectively interrupt the transmission of pain-related signals and thus reduce the perception of pain.”

Enkephalin is one member of the family of opioid peptides that are naturally produced in the body. Opioid peptides exert their pain- relieving effects by acting at the same receptor through which morphine and related opiate drugs achieve their pain-relieving effects. In this trial the enkephalin peptide, produced as a result of the gene transfer, will be released selectively in the spinal cord at a site involved in transmitting pain from the affected body part to the brain.

“We hope that this selective targeting will result in pain-relieving effects that cannot be achieved by systemic administration of opiate drugs, “ Fink says. “This trial is the first step in bringing the therapy into clinical use. A treatment is at least several years off.”

Friday, September 19, 2008

CAN THE WAY you chew a raisin affect the way you experience pain? Trials at St James's and AMNCH (Tallaght) Hospitals in Dublin are beginning to look at how "mindfulness meditation" can be used to help people cope with a diverse range of problems including chronic pain, depression, anxiety, cardiac difficulties and even psoriasis.

"Mindfulness is a secular form of meditation . . . [and] . . . is useful for anyone going through stress and strain in life, which is probably everybody," explains Dr Noirin Sheahan, who has been practising mindfulness meditation for 20 years.

"In 2004, I realised that it was being used clinically . . . [and] . . . about a year ago, a consultant in pain medicine, Dr Connail McCrorey, asked me to teach his patients with chronic pain mindfulness," says Sheahan.

So what is mindfulness meditation? To most, these words conjure up images of Eastern spirituality, incense sticks and chanting. However, while the roots of it are indeed in Hindu and Buddhist philosophies, it's use in its present form started with the work of a US molecular biologist.

Dr Jon Kabat-Zinn, a researcher who specialised in the mind-body interaction, had been practising Zen Buddhism for many years. He realised that "what he had learned in terms of coping with the difficulties in life . . . could be applied in society as a whole outside of Buddhism", according to Sheahan.

"He felt that the place where the difficulty of life is most manifest is in hospitals where people are trying to cope with disease, chronic illness, maybe even terminal illness." As a result, "he developed an eight-weeks course . . . [in which] there is no chanting, no candles, incense, etc."

Wednesday, September 17, 2008

When people have a heart attack, a classic symptom is shooting pain down the left arm. That symptom, it turns out, has something in common with a far more benign kind of pain: the headache one can get from eating ice cream too fast.

Both are examples of what doctors call referred pain, or pain in an area of the body other than where it originates. Such sensory red herrings include a toothache resulting from a strained upper back, foot soreness caused by a tumor in the uterus, and hip discomfort when the problem is really arthritis in the knee.

Referred pain can make diagnoses difficult and can lead to off-target or wholly unnecessary cortisone injections, tooth extractions and operations. Now, in trying to discover the patterns and causes of the phenomenon, researchers say they are gaining a greater understanding of how the nervous system works and how its signals can go awry.

"The body can really fool you in terms of determining pathology," said Karen J. Berkley, a professor of neuroscience at Florida State University. Her research has focused on referred pain caused by endometriosis — pain that can be felt as far away as the jaw.

One possible explanation has to do with the way the body's nerve fibers converge on and send signals up the spinal column. Each nerve input carries an astonishing amount of information about the body.

"What we think happens is that the information sometimes loses its specificity as it makes its way up the spinal column to the brain," Dr. Berkley said. In the constant dynamic of excitation and inhibition that occurs during the transport of innumerable nerve impulses, she went on, "we can't always discern where a sensory message is coming from."

Usually the mixed signals come from nerves that overlap as they enter the spinal column — from the heart and left arm, for example, or from the gallbladder and right shoulder. This so-called adjacency of neural inputs probably explains why some people report a sensation in their thighs when they need to have a bowel movement or feel a tingling in their toes during an orgasm.

Moreover, when the stimulus emanates from internal organs, the sensation is often perceived as coming from the chest, arms, legs, hands or feet. "The brain is more used to feeling something out there than in the viscera," explained Gerald F. Gebhart, director of the Center for Pain Research at the University of Pittsburgh.

In a study published last year, researchers at Aalborg University in Denmark applied irritating substances like capsaicin (the stuff that makes chili peppers hot) to subjects' small and large intestines. They found increased blood flow and elevated temperatures in referred-pain sites in the trunk and extremities. (The study appeared in The European Journal of Pain.)

Pain can also be referred to areas that do not have overlapping nerves. This most often occurs after an injury, according to Dr. Jon Levine, a neuroscientist at the University of California, San Francisco. This, he said, might be because of "pain memory," which makes the brain more likely to "experience a new sensation as coming from where you were hurt before."

Carolyn Bernstein was sitting in a lecture hall one day during her second year at Boston University Medical School when her head began to pound and throb. She became dizzy and disoriented and felt so weak she thought she would faint. Bernstein managed to leave class and get home, where she collapsed into bed. She was suffering from her first migraine and she soon found out that there was no easy treatment. Bernstein says migraineurs—people who get migraines—are too often treated with condescension by doctors who tell them to "just deal with it."

Her experience led her to specialize in migraines. In addition to being on the faculty at Harvard Medical School, she also runs the Women's Headache Center in Cambridge, Mass. Unfortunately, such centers are rare and most migraineurs still struggle to find help. Bernstein says that's why she wrote her new book, "The Migraine Brain" (Free Press, 2008). Each migraineur's experiences are unique, Bernstein says. Some have attacks that last only a few hours; others can be in pain for days. Women are more likely to get migraines than men, for reasons doctors still don't fully understand. Migraines can't be cured, only treated with a range of medication and lifestyle changes. "I want to encourage people to seek help and not feel alone," Bernstein says. We asked Bernstein for a quick rundown on the science of migraines.

Fortunately, you have alternatives — natural ones. From herbs that attack inflammation to techniques that leverage the brain's remarkable healing powers, nature offers many treatments for conditions such as arthritis, fibromyalgia, and even muscle strains.

Here are eight natural remedies that may enhance or replace conventional antidotes, and leave you happier, healthier, and pain free.

Capsaicin: For arthritis, shingles, or neuropathyWhat the science says: An active component of chile pepper, capsaicin temporarily desensitizes pain-prone skin nerve receptors called C-fibers; soreness is diminished for 3 to 5 weeks while they regain sensation. Nearly 40 percent of arthritis patients reduced their pain by half after using a topical capsaicin cream for a month, and 60 percent of neuropathy patients achieved the same after 2 months, according to a University of Oxford study. Patients at the New England Center for Headache decreased their migraine and cluster headache intensity after applying capsaicin cream inside their nostrils.

How to try it: Capsaicin ointments and creams are sold in pharmacies and health stores. For arthritis or neuropathy, try 0.025 percent or 0.075 percent capsaicin cream one to four times daily; best results can take up to 2 weeks, says Philip Gregory, PharmD, a professor at Creighton University and editor of the Natural Medicines Comprehensive Database. But research on capsaicin and headaches remains limited — and don't expect stronger versions anytime soon: "Current formulations are better suited for more acute problems, like a sore muscle or an arthritis flare-up, than everyday pain and stiffness," Gregory says.

InflaThera or Zyflamend: For arthritisWhat the science says: Both supplement brands contain ginger, turmeric, and holy basil, all of which have anti-inflammatory properties. Turmeric (a curry ingredient) may be the best: A component, curcumin, eases inflammatory conditions like rheumatoid arthritis and psoriasis, according to the Methodist Research Institute in Indianapolis. Researchers are now testing Zyflamend in RA patients, but some experts are already sold: "Each herb has its own scientific database of evidence," says James Dillard, MD, author of "The Chronic Pain Solution."

How to try it: ProThera, InflaThera's maker, will only sell to health care professionals, so your doctor has to order it for you; that said, it's reportedly stronger (and slightly cheaper) than Zyflamend. InflaThera's suggested dosage is twice daily with food. For the more readily accessible Zyflamend, take one capsule two or three times daily, but avoid it near bedtime — each pill contains 10 mg of caffeine (another version, Zyflamend PM, is reportedly less stimulating). Buy Zyflamend at swansonvitamins.com or immunesupport.com/zyflamend.htm. Or, save money and try curcumin to start: Taking 500 mg four times daily, along with fish oil and a diet low in animal fat, can ease arthritis, says Jane Guiltinan, ND, immediate past president of the American Association of Naturopathic Physicians.

Arnica: For acute injury or post surgery swellingWhat the science says: This herb comes from a European flower; although its healing mechanism is still unknown, it does have natural anti-inflammatory properties. Taking oral homeopathic arnica after a tonsillectomy decreases pain, say British researchers, and German doctors found that it reduces surgery-related knee swelling.

How to try it: Use homeopathic arnica as an adjunct to ice, herbs, or conventional pain meds, suggests Guiltinan. Rub arnica ointment on bruises or strained muscles, or take it in the form of three lactose pellets under the tongue up to six times per day. Boiron is among the most reputable arnica manufacturers.

Aquamin: For osteoarthritisWhat the science says: This red seaweed supplement is rich in calcium and magnesium. A preliminary clinical study showed that the ingredients may reduce joint inflammation or even help build bone, says David O'Leary of Marigot, Aquamin's Irish manufacturer. In a study of 70 volunteers published in Nutrition Journal, Aquamin users reduced arthritis pain by 20 percent in a month, and had less stiffness than patients taking a placebo.

How to try it: Marigot recommends 2,400 mg a day (two capsules) of Aquamin in tablet form, sold domestically in products such as Aquamin Sea Minerals and Cal-Sea-Um. A 60-pill jar of Swanson Vegetarian Aquamin Sea Minerals costs about $6 at swansonvitamins.com.

SAM-e (S adenosylmethionine): For osteoarthritisWhat the science says: SAM-e is made from a naturally occurring amino acid and sold as capsules. Doctors aren't entirely sure why it tamps down pain, but it reduces inflammation and may increase the feel-good brain chemicals serotonin and dopamine.

Studies by the University of Maryland School of Nursing and the University of California, Irvine, showed that SAM-e was as effective as some NSAIDs in easing osteoarthritis aches; the California researchers found that SAM-e quashed pain by 50 percent after 2 months, though it took a few weeks to kick in. SAM-e produced no cardiovascular risks and fewer stomach problems than the conventional meds.

How to try it: Costco and CVS both carry it; a month's supply costs $30 to $60. Guiltinan prescribes 400 to 1,600 mg daily, often with turmeric or fish oil. SAM-e can interact with other meds, especially MAO-inhibitor antidepressants, so it's vital to talk with your doctor before taking it (and avoid SAM-e entirely if you have bipolar disorder).

Also, inspect the packaging before buying, advises Gregory: Make sure the product carries a USP or GMP quality seal, contains a stabilizing salt, has a far-off expiration date, and comes in foil blister packs — SAM-e can degrade rapidly in direct light.

Fish oil: For joint pain from arthritis or autoimmune disordersWhat the science says: Digested fish oil breaks down into hormonelike chemicals called prostaglandins, which reduce inflammation. In one study, about 40 percent of rheumatoid arthritis patients who took cod-liver oil every day were able to cut their NSAID use by more than a third, Scottish scientists recently reported. People with neck and back pain have fared even better: After about 10 weeks, nearly two-thirds were able to stop taking NSAIDs altogether in a University of Pittsburgh study.

How to try it: Taking 1,000 mg is proven to help your heart, but you should up the dose for pain. For osteoarthritis, try 2,000 to 4,000 mg daily; for rheumatoid arthritis and autoimmune diseases associated with joint pain (such as lupus), consider a much higher dose of upwards of 8,000 mg daily — but ask your doctor about such a large amount first, says Tanya Edwards, MD, medical director at the Cleveland Clinic's Center for Integrative Medicine. (The same rule applies if you take BP or heart meds, as omega-3s can thin the blood.) Read the nutrition label carefully: The dosage refers to the amount of omega-3s in a capsule, not other ingredients. Nordic Naturals (nordicnaturals.com) and Carlson (carlsonlabs.com) are both reputable brands; for something stronger, GNC's Triple-Strength Fish Oil (gnc.com) has 900 mg of omega-3s per capsule.

Methylsulfonyl-methane (MSM): For osteoarthritisWhat the science says: MSM is derived from sulfur and may prevent joint and cartilage degeneration, say University of California, San Diego, scientists. People with osteoarthritis of the knee who took MSM had 25 percent less pain and 30 percent better physical function at the end of a 3-month trial at Southwest College of Naturopathic Medicine and Health Sciences. Indian researchers also found that MSM worked better when combined with glucosamine.

How to try it: Start with 1.5 to 3 g once daily and increase to 3 g twice daily for more severe pain, suggests Leslie Axelrod, ND, a professor of clinical sciences at Southwest. Patients in the Indian trial improved on dosages as low as 500 mg three times daily. Vendors of OptiMSM, the brand tested in Axelrod's trial, can be found at optimsm.com.

Counting out loud: For brief "needle stick" painWhat the science says: Patients who counted backward from 100 out loud during an injection experienced and recalled less pain, according to a recent Japanese study. None of the 46 patients who counted complained afterward, and only one of them could remember pain from the injection at all (among the 46 who didn't count, 19 said the injection hurt and 10 recalled what it felt like). Recitation might work by distracting the brain from processing the sensation, says study author Tomoko Higashi, MD, of Yokohama City University Medical Center in Kanagawa, Japan. The trick is probably only useful for short or acute periods, she says, adding: "The degree of pain reduction really depends on how well patients concentrate on counting."

Thursday, September 11, 2008

Organized by the Pain of Urological Origin (PUGO) special interest group of the International Association for the Study of Pain (IASP) Glasgow, Scotland, August 15-16, 2008.

PUGO held a 2 day meeting in Scotland prior to the IASP 12th World Congress on Pain to consider the past, present and future of urogenital pain. The aim was to outline current practice and have a look at what the future may hold. Speakers from North America and Europe gave invited lectures, and interactive sessions with all meeting attendees were interspersed throughout the proceedings leading to very lively discussions. The organizing committee included: Andrew Baranowski from London, John Hughes from Middlesbrough, UK, Beverly Collett from Leicester, UK, Ursula Wesselmann from Birmingham, Alabama, Leroy Nyberg from Bethesda, MD, Richard Berger from Seattle, Curtis Nickel from Kingston, Ontario, and Paul Abrams from Bristol, UK. The meeting was attended by a broad range of specialists in pain medicine, anesthesiology, psychology, neurology, neurosurgery, urology, gynecology, physical therapy, and internal medicine. Patient advocates were also enthusiastic participants. Many excellent presentations were given, and this report can only highlight selected ones. The proceedings will be synthesized by the organizing committee and faculty and a formal publication is planned.

An extensive in-depth review of pharmacologic interventions (prescription, over-the-counter, complementary and alternative) used to treat patients with chronic pain, including a comprehensive appendix on guidance for the use of opioids.

Strong evidence indicating that best practices for treatments of various chronic pain conditions should differ.

Evidence that in the absence of a curative intervention, teaching and learning coping skills will result in superior outcomes and are consequently highly advisable.

Incorporation of patient education information, including the criticality of maintaining activities, avoiding disuse and focusing on function.

Discussion of the use of progressive exercise programs to facilitate maximal medical improvements, increased functional status, return to limited work, or in best cases, return to unrestricted work as cornerstone therapies.

Recommendations for clinicians to address psychosocial and workplace factors that may be impeding patient recovery to facilitate functional improvement.

Emphasis on the need for the clinical evaluation to provide a comprehensive picture of the physical, psychological and socio-environmental factors that may be contributing to pain and the use of descriptions of current functional activities rather than pain ratings, to quantify the impact of pain.

A focus on functional restoration including an active exercise program and behavioral program as patients do best when returned to functional status sooner, including through use of work conditioning, work hardening, graded exercise programs and participatory ergonomic and return to work programs.

A comprehensive appendix which covers treatment options for patients with tender points/fibromyalgia, although this is not considered an occupational disorder.

A table which summarizes the recommendations by chronic pain disorder.

Algorithms for the different chronic pain conditions which offer quick and accurate guidance for cases with different progressions, circumstances, or outcomes.

An extensive volume of literature relied upon to develop the evidence-based recommendations contained in the chapter—1,557 references including 546 randomized controlled trials.

Wednesday, September 03, 2008

Exercising may sometimes be a pain in the neck, but it can actually relieve some types of back pain, studies show.

In fact, when it comes to chronic lower-back pain, supervised stretching and muscle strengthening exercises may relieve the ache best.

Canadian researcher Dr. Jill A. Hayden, of the Institute for Work and Health in Toronto, led two reviews focusing on the effects of different exercise programs on various types of low back pain. Both were published in the journal Annals of Internal Medicine.

The first review looked at more than 60 studies investigating the effect of exercise in general on different types of low back pain. The research included in the review involved nearly 6,400 people with back pain. Their back pain was categorized as acute (short-term and relatively severe), subacute, or chronic (lasting for more than three months).

While the trials showed a small benefit from gradually introducing and increasing exercise for subacute back pain and no clear benefit from exercise therapy on acute low back pain, there was "strong evidence" that exercise helped the people with chronic pain.

Having established the benefits of exercise for this particular group, Dr. Hayden then narrowed her focus to the 43 studies included in the original review that specifically looked at chronic low back pain, in order to determine what types of exercise may provide the biggest benefit.

The 43 studies looked at the effects of more than 70 different exercise treatments, which varied by level of supervision, type of exercise, frequency and duration of exercise, and more. For type of exercise, they found stretching and strengthening routines to be most effective at relieving pain and restoring function. What's more, "an individually designed, high-dose exercise program delivered through home exercises with regular practitioner follow-up" was found to have the most positive impact.

The researchers also noted that other treatment, such as over-the-counter pain relievers and manual therapy, may produce an increased benefit on top of the exercise.

But they added that benefits from any exercise program depend on the person with back-pain sticking with their routine, and noted that "strategies should be used to encourage adherence."

While back pain can't always be avoided, as in the case of injuries, the best treatment is always prevention. Consider these tips to minimize your risk:

Maintain a healthy body weight to minimize stress on the back.

Avoid prolonged sitting or standing.

Add Pilates or another form of exercise that increases abdominal, back, and leg strength for added support.

Wear supportive shoes.

Take care to support your back and use the strength in your legs when lifting objects.